For years, enhancing healthcare access and quality for Medicaid recipients has been a paramount objective for states nationwide. The Patient-Centered Medical Home (PCMH) model gained traction as a framework for delivering comprehensive primary care. Building on this, the Affordable Care Act (ACA) of 2010 further empowered state Medicaid programs to establish health homes. These health homes aimed to integrate and improve the coordination of a wide spectrum of services for Medicaid beneficiaries grappling with chronic health conditions. Tennessee seized this opportunity, concurrently launching a PCMH program to address the primary care needs of all Medicaid beneficiaries and a specialized health home program, known as Tennessee Health Link (THL), to coordinate both behavioral and physical health services for those with significant behavioral health needs. The PCMH program commenced in January 2017, closely followed by THL in December 2016.
TennCare, Tennessee’s Medicaid agency, recognized a critical need for both PCMH and THL providers: comprehensive patient information. To effectively manage and improve patient care, providers required readily accessible data on service needs and services rendered to their Medicaid patients. However, the absence of a functioning state health information exchange (HIE) in Tennessee since its disbandment in 2012 posed a significant hurdle. No centralized system existed to aggregate and transform raw data into actionable insights for providers. To bridge this critical information gap, TennCare developed the Care Coordination Tool (CCT). This innovative tool gathers data from diverse sources to empower PCMH and THL providers in addressing the primary and behavioral healthcare needs of their Medicaid patients. This article delves into the Tenncare Care Coordination Tool, drawing upon research and insights from interviews with TennCare representatives, to understand its functionalities and impact.
Unpacking the TennCare Care Coordination Tool (CCT)
The TennCare care coordination tool (CCT) is a sophisticated, cloud-based application designed to consolidate and present vital patient information to healthcare providers. It aggregates data from a multitude of sources, creating a holistic view of a patient’s healthcare journey. Key data feeds for the CCT include:
- Medicaid Claims Data: Comprehensive records of services billed to Medicaid, offering a historical perspective on patient care utilization.
- Encounter Data from Managed Care Organizations (MCOs): Data from TennCare’s contracted MCOs, capturing detailed information about patient encounters within managed care networks.
- Immunization Data from TennIIS: Access to the Tennessee Department of Health’s (TDH) statewide immunization information system (TennIIS) ensures up-to-date immunization records.
- Admissions, Discharges, and Transfers (ADT) Data: Near real-time notifications of hospital admissions, discharges, and transfers, facilitated through data exchange partnerships with the Tennessee Hospital Association (THA), East Tennessee Health Information Network (etHIN), and Community Hospital Systems (CHS).
By synthesizing this diverse information, the TennCare care coordination tool empowers providers to proactively identify and address gaps in patient care. The timely notification of hospitalizations and emergency department visits is particularly crucial, enabling providers to deliver prompt transitional and follow-up care, improving patient outcomes and reducing readmission rates. The CCT provides specific, actionable information, including:
- Patient Demographics and Panel Information: Essential identifying information for Medicaid beneficiaries within a provider’s patient panel.
- Claims-Based Clinical Data: A consolidated clinical history derived from claims and encounter data, encompassing medication history, diagnoses, and records of provider visits.
- Real-time ADT Notifications: Immediate alerts regarding patient encounters in emergency departments and hospitals, facilitating timely intervention.
- Immunization Status: Current immunization data, particularly for children under 2 and adolescents aged 9-13, crucial for preventative care.
- Performance on Quality Measures: Visibility into provider performance on key quality metrics tied to PCMH and THL value-based payment models, promoting accountability and quality improvement.
- Care Alerts for “Past Due” Services: Proactive alerts for necessary but overdue services, such as mammograms, post-hospital discharge follow-ups, or updates to patient-centered care plans, ensuring comprehensive care delivery.
Participation in the TennCare PCMH and THL programs offers providers opportunities for bonus payments based on their performance in total cost of care, efficiency, and quality metrics. The CCT, while optional, serves as a vital platform for providers to leverage near real-time data and monitor the impact of their interventions on these performance measures. Detailed information on payment structures can be found in TennCare’s PCMH and Health Link operational manuals.
The Power of Integrated Data Sources in the TennCare CCT
“Reach out to providers early…find out their wishlist. What is it that would help them take care of their patients better?”
—TennCare representative
The TennCare care coordination tool (CCT) is designed to be a central information hub for PCMH and THL providers. It addresses the fragmented nature of healthcare data by offering a unified view of patient information, even when patients are enrolled across different MCOs. By aggregating data related to primary care needs, services received, and hospital interactions, the CCT streamlines access to critical patient insights. While TennCare leverages its Medicaid Management Information System (MMIS) as a core data source, the agency recognized the limitations of relying solely on claims data. One significant challenge is the inherent time lag in claims processing, which can delay access to timely information. Another obstacle is the lack of seamless integration between the CCT and providers’ Electronic Health Records (EHRs), potentially leading to duplicate data entry and workflow inefficiencies. These challenges underscore the importance of continuous improvement and expansion of the CCT’s capabilities.
To overcome these data limitations and enhance the value of the TennCare care coordination tool, TennCare strategically forged partnerships with organizations holding complementary data assets. The Tennessee Hospital Association (THA) became TennCare’s first key partner in 2017, enabling the integration of near real-time ADT data into the CCT. Recognizing the need for comprehensive ADT coverage, TennCare collaborated with THA to expand data submission to include hospitals not yet participating in the THA data exchange. Notably, TennCare implemented a policy requiring hospitals to submit ADT data to qualify for directed payments, incentivizing widespread participation. This initiative resulted in 100% hospital ADT data submission to THA, creating a robust and complete ADT dataset within the CCT.
In 2019, TennCare further expanded the CCT’s data landscape by contracting with the Tennessee Department of Health (TDH) to incorporate immunization data from TennIIS. This integration supplements claims-based immunization data, enhancing the accuracy of HEDIS immunization measures and proactively identifying patients requiring vaccinations. This partnership is mutually beneficial, as it also commits TennCare to collaborate with TDH in improving data quality and provider participation in TennIIS, furthering the shared goal of improving childhood immunization rates across Tennessee.
“One of the biggest draws was that live ADT feed. It helped care coordinators keep up to date with admissions, emergency department use, and discharges so that they could follow-up in real time.”
—TennCare representative
While the specific data partnerships established by TennCare may be unique to Tennessee, the underlying principles are broadly applicable. TennCare’s experience highlights the importance of meticulous planning to identify essential data elements for the care coordination tool, both at launch and for future enhancements. Identifying potential data partners and establishing mutually beneficial agreements are critical steps in accessing data beyond the Medicaid agency’s direct control. Building these partnerships and developing robust contractual frameworks requires dedicated time and a long-term strategic vision from the outset of tool development.
Investing in the TennCare CCT: A Strategic Imperative
Developing and maintaining the TennCare care coordination tool (CCT) represents a significant investment, demanding leadership commitment and cross-departmental collaboration. TennCare engaged diverse internal teams, including the chief medical office, behavioral health operations, information systems, and legal counsel. Crucially, the development process incorporated valuable input and feedback from PCMH and THL providers and MCOs, ensuring the tool’s relevance and usability. Beyond vendor contracts with HealthEC (the CCT vendor), THA, and TDH, TennCare also leveraged its information system (IS) contractors for design and implementation expertise. TennCare estimates that a core team of 15-20 individuals were deeply involved in the CCT’s development, with broader engagement as needed.
The most substantial investment lies in the ongoing costs of developing and operating the CCT. TennCare initially conducted a competitive procurement process in 2016 to select a vendor for the first CCT iteration. The second-generation CCT, launched in November 2020, was procured through an existing TennCare IS contractor. TennCare representatives emphasize that the current CCT more effectively aligns with their vision for the tool and the evolving needs of THL and PCMH organizations.
Drawing upon their experience, TennCare offers key recommendations for states considering similar care coordination tools. Vendor selection is paramount. States should prioritize vendors with proven expertise in handling and processing complex healthcare data accurately. Data inaccuracies can quickly erode provider trust in the tool. TennCare advises states to:
- Establish Vendor Qualification Criteria: Define essential vendor qualifications and involve knowledgeable IT staff in evaluating vendor capabilities against these criteria.
- Prioritize Experienced Vendors: Select vendors with a track record of working with large, multi-site healthcare organizations and managing diverse data streams from multiple sources.
- NCQA Measure Certification: If HEDIS measure generation is a requirement, ensure the vendor possesses National Committee for Quality Assurance (NCQA) Measure Certification.
“After you choose a vendor, set strategy immediately. The strategy should be as detailed and inclusive as possible, but general enough to grow to what you need in the future.”
—TennCare representative
- Engage End-Users in Design: Actively solicit input from providers who will utilize the tool. Consider establishing technical assistance groups or conducting user testing to refine design and functionality.
- Conduct Thorough Reference Checks: Perform detailed reference checks on potential vendors to gain insights into their strengths and weaknesses from previous clients.
- Develop a Post Go-Live Training and Engagement Plan: Implement a comprehensive training and engagement strategy for the 12 months following tool launch to ensure effective user adoption and ongoing support.
While the initial investment in the CCT was substantial, the original implementation qualified for a 90/10 federal match under the Health Information Technology for Economic and Clinical Health (HITECH) Act. Currently, as an integral component of TennCare’s MMIS, the HealthEC CCT receives a 75/25 federal match. These federal funding mechanisms significantly mitigate the state’s financial burden. (Note: While HITECH funding concluded in 2021, alternative funding opportunities remain available to secure 90 percent federal funding for HIE and HIT design and development.)
Demonstrating Success: Evidence of the TennCare CCT’s Impact
A key indicator of the TennCare care coordination tool’s (CCT) success is provider adoption and utilization. As of June 2021, all PCMHs, THLs, and MCOs in Tennessee have registered at least one staff member to use the tool, with a total of 662 registered users across these organizations. TennCare representatives report that the enhanced ADT data feed has been a major driver of provider engagement. To support users, TennCare provides ongoing monthly training sessions and personalized assistance. Furthermore, TennCare and its contractor have developed a comprehensive learning library featuring training recordings and quick reference guides to assist providers in leveraging the CCT for various tasks, such as identifying frequent emergency department users.
However, the ultimate measure of success lies in whether the CCT demonstrably improves cost and quality outcomes for Medicaid beneficiaries. Attributing direct causality is complex due to the multitude of factors influencing healthcare costs and quality. Nevertheless, TennCare has conducted evaluations of both the PCMH and THL programs, and agency representatives believe these evaluations suggest that the CCT has played a positive role in driving improved outcomes. Key findings from these evaluations include:
“There are some members THL providers cannot find. With ADT, they can locate and maybe enroll the member if they show up at the hospital.”
—TennCare representative
While definitive causal links are challenging to establish, TennCare believes the CCT has contributed to these improvements by facilitating the identification of care gaps and providing actionable information to enhance follow-up and care coordination. This belief is reinforced by feedback gathered from focus groups and interviews with PCMH and THL providers. Providers consistently highlighted the CCT’s value in care coordination, particularly the ADT data. Moreover, many providers expressed a desire for even more comprehensive data integration, underscoring the perceived value of the information provided by the CCT. Anecdotal evidence further suggests that the CCT has empowered providers to better understand the specific primary care and behavioral health needs of their patients and facilitate timely access to appropriate care.
Conclusion: TennCare CCT as a Model for Data-Driven Care Coordination
TennCare’s experience showcases a successful model for state Medicaid agencies to develop effective IT tools that empower providers to enhance care delivery for Medicaid beneficiaries, even in the absence of a statewide HIE. The TennCare care coordination tool’s success is rooted in a provider-centric approach. TennCare prioritized end-user needs throughout the CCT’s development, ensuring the tool delivers accurate, near real-time data to improve care coordination and focuses on providing actionable information that directly supports provider performance linked to value-based payments. To achieve this, TennCare proactively sought data sources beyond its own agency, creating a more comprehensive and timely dataset, and cultivated strong partnerships with the state’s IS agency and external data providers. Finally, access to enhanced federal matching funds helped offset the substantial investment required. The TennCare care coordination tool serves as a valuable case study for other states seeking to leverage health IT to improve care coordination and outcomes within their Medicaid programs.
Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank the state officials from Tennessee who contributed to the brief as well as Health Resources and Services Administration Project Officer Diba Rab and her colleagues for their feedback and guidance. We also thank the state officials from Montana and the staff of the Montana Healthcare Foundation whose interest in improving the care delivered to Montana Medicaid participants led to the creation of this brief. Finally, the author wishes to thank Hemi Tewarson, Kitty Purington, Jodi Manz, and Luke Pluta-Ehlers of NASHP for their contributions to the paper. This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under co-operative agreement number UD3OA22891, National Organizations of State and Local Officials. The information, content, and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.
